MEDICARE: HYMERA EMERGENCY RESPONSE TEAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	0439	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000203079	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1639188378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYMERA EMERGENCY RESPONSE TEAM

Provider Business Mailing Address
First Line	:	50 E JACKSON ST
Second Line	:
City	:	HYMERA
State	:	IN
Zip	:	47855
Country	:	US
Telephone Number	:	260-383-5155
Fax Number	:

Provider Business Practice Location Address
First Line	:	3134 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2882
Country	:	US
Telephone Number	:	260-436-9495
Fax Number	:	260-436-7235

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CLAY SHIDLER
Credential	:
Telephone Number	:	812-383-5155

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	08/22/2020

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